Acacia Living Group Meadow Springs Aged Care Facility

82 Oakmont Avenue, MEADOW SPRINGS, WA, 6210

1. Assessment Contact - SiteAug 31, 2023

   Prepared by M Glenn

   source ↗
2. Assessment contact Performance ReportJul 12, 2023

   An assessment contact was conducted with this service on 11 July 2023 to 12 July 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

   source ↗
3. Accreditation decisionJan 18, 2023

   Following a site audit conducted on 06 December 2022 to 08 December 2022, the Commission made a decision on 18 January 2023 to re-accredit this service. The period of accreditation of the service will expire on 13 February 2026.

   source ↗
4. Site AuditJan 18, 2023

   Prepared by T Wilson

   source ↗
   AI report insightsAI-extracted · qwen2.5:32b

   The performance report indicates that Acacia Living Group Meadow Springs Aged Care Facility is compliant in most areas but faces significant challenges in ensuring consumer dignity, managing personal care and clinical care documentation, handling feedback and complaints effectively, monitoring staff performance, and maintaining robust governance systems. The provider has acknowledged these issues and proposed continuous improvement plans to address the identified non-compliances.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service was found to be non-compliant with Requirement 1(3)(a) as some consumers were not treated with dignity and respect, despite the provider's continuous improvement plan.

   • Not met Requirement 1(3)(a) — Staff could be impatient and spoke to consumers in a manner that did not preserve their dignity or show respect. Some staff made intimidating comments, and one consumer was left unassisted with continence issues.
   • Met Requirement 1(3)(b) — Consumers' cultural needs were identified in care plans and lifestyle programs included multicultural celebrations.
   • Met Requirement 1(3)(c) — Consumers confirmed they are supported to make decisions about their own care, communicate choices, and maintain relationships of choice.
   • Met Requirement 1(3)(d) — Consumers were enabled to take risks through the risk assessment process with mitigating strategies reviewed regularly.
   • Met Requirement 1(3)(e) — Information provided to consumers was current, accurate, and communicated in a way that is clear and easy to understand.
   • Met Requirement 1(3)(f) — Consumers' privacy was respected with confidential handling of personal information.

   Risks: Some staff spoke in a derogatory manner about consumers, leaving them feeling despondent and disrespected.

   Recommendations: Training for staff on dignity, values, understanding diversity, and the provider’s code of conduct.; Improved communication with registered staff on individualised care that maintains each person's dignity.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service was compliant in all requirements as it effectively communicated outcomes to consumers, documented risks, and reviewed care plans regularly.

   • Met Requirement 2(3)(a) — Assessment documents identified medical, cognitive, infection, sensory, pressure area, falls risks and strategies to inform safe care delivery.
   • Met Requirement 2(3)(b) — Care plans included consumer preferences and current needs, including end-of-life care wishes.
   • Met Requirement 2(3)(c) — Staff worked with consumers and representatives to ensure care aligns with their needs and preferences.
   • Met Requirement 2(3)(d) — Consumers confirmed they are kept informed of assessment outcomes and changes in care delivery.
   • Met Requirement 2(3)(e) — Care plans were updated to reflect any changes made during reviews following health declines, incidents, or preference changes.

   Standard 3 Personal care and clinical careNon-compliant

   The service was non-compliant with Requirement 3(3)(e) due to ineffective documentation and communication of consumer information, leading to issues in managing diabetes and pain during transfers.

   • Met Requirement 3(3)(a) — Consumers received safe and effective personal and clinical care that is tailored to their needs.
   • Met Requirement 3(3)(b) — High impact or high prevalence risks were managed effectively with validated assessment tools.
   • Met Requirement 3(3)(c) — Consumers nearing the end of life received compassionate care that maximised comfort and preserved dignity.
   • Met Requirement 3(3)(d) — Staff promptly responded to changes in consumers' mental health, cognitive or physical function.
   • Not met Requirement 3(3)(e) — Information about a consumer’s diabetic management plan was not documented and staff were unaware of the correct medication charts. Another consumer suffered pain during transfers due to incomplete information on transfer procedures.
   • Met Requirement 3(3)(f) — Timely referrals were made to other care providers as needed.
   • Met Requirement 3(3)(g) — Infection control practices and antibiotic usage were managed appropriately with staff training and oversight.

   Risks: A diabetic consumer was treated incorrectly due to outdated care plans, leading to unstable blood sugar levels.; Another consumer suffered pain during transfers as information on transfer procedures was incomplete.

   Recommendations: Implementation of a new clinical handover process and weekly multidisciplinary team meetings.; Regular review of progress notes and daily huddles for staff education.

   Standard 4 Services and supports for daily livingCompliant

   The service was compliant in all requirements, providing safe and effective services that met consumers' needs and preferences.

   • Met Requirement 4(3)(a) — Consumers confirmed they received services meeting their needs, goals, and preferences.
   • Met Requirement 4(3)(b) — Services promoted emotional, spiritual, and psychological well-being with access to psychological and faith support programs.
   • Met Requirement 4(3)(c) — Consumers were supported in maintaining social connections and participating in activities of interest.
   • Met Requirement 4(3)(d) — Information about consumers' conditions, needs, and preferences was communicated effectively within the organization.
   • Met Requirement 4(3)(e) — Timely referrals were made to other care providers as needed.
   • Met Requirement 4(3)(f) — Consumers confirmed satisfaction with the variety and quality of meals provided.
   • Met Requirement 4(3)(g) — Equipment was safe, suitable, clean, and well maintained as observed by staff and consumers.

   Standard 5 Organisation’s service environmentCompliant

   The service was compliant in all requirements with a welcoming, safe, and comfortable environment that supported consumer independence and interaction.

   • Met Requirement 5(3)(a) — Consumers found the service environment to be clean, safe, well maintained, and comfortable.
   • Met Requirement 5(3)(b) — The facility was observed to be welcoming with a high standard of presentation and cleanliness.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment were safe, clean, well maintained, and suitable for consumers.

   Standard 6 Feedback and complaintsNon-compliant

   The service was non-compliant with Requirements 6(3)(c) and 6(3)(d), as appropriate action was not always taken in response to complaints, leading to a lack of quality improvement.

   • Met Requirement 6(3)(a) — Consumers and representatives confirmed they knew how to provide feedback and complaints.
   • Met Requirement 6(3)(b) — Consumers were aware of advocates, language services, and other methods for raising and resolving complaints.
   • Not met Requirement 6(3)(c) — Appropriate action was not always taken in response to complaints, leading to a lack of quality improvement.
   • Not met Requirement 6(3)(d) — Feedback and complaints were not reviewed effectively to improve the quality of care and services.

   Risks: Consumers and representatives stated they had not seen any changes made as a result of their issues raised.

   Recommendations: Education for staff on feedback management, acknowledging, actioning, and following up complaints.; Monthly analysis to monitor trends, review actions, and implement improvements.

   Standard 7 Human resourcesNon-compliant

   The service was non-compliant with Requirements 7(3)(b) and 7(3)(e), as some staff interactions were not kind or respectful, and performance monitoring was inadequate.

   • Met Requirement 7(3)(a) — The workforce was planned to deliver safe and quality care with enough staff.
   • Not met Requirement 7(3)(b) — Some consumers stated that staff did not treat them with kindness or respect, including shouting at a consumer with cognitive impairment.
   • Met Requirement 7(3)(c) — Staff were competent and had the qualifications to perform their roles effectively.
   • Met Requirement 7(3)(d) — The workforce was recruited, trained, equipped, and supported to deliver required outcomes.
   • Not met Requirement 7(3)(e) — Performance monitoring of staff was inadequate with incidents of unacceptable behavior not being progressed as per policy.

   Risks: Staff interactions were unkind, including shouting at a consumer and speaking derogatorily about consumers in their presence.

   Recommendations: Implementation of a schedule for staff appraisals.; File notes to assist with staff monitoring and performance management.

   Standard 8 Organisational governanceNon-compliant

   The service was non-compliant with Requirements 8(3)(c) and 8(3)(d), as governance systems were not effective in managing information, continuous improvement, feedback, complaints, and risk management.

   • Met Requirement 8(3)(a) — Consumers were engaged in the development, delivery, and evaluation of care and services.
   • Met Requirement 8(3)(b) — The governing body promoted a culture of safe, inclusive, and quality care with oversight structures.
   • Not met Requirement 8(3)(c) — Governance systems were not effective in managing information, continuous improvement, feedback, and complaints.
   • Not met Requirement 8(3)(d) — Risk management systems did not ensure all incidents were investigated and recorded, and staff were not equipped to identify or manage high-impact risks effectively.
   • Met Requirement 8(3)(e) — A clinical governance framework was in place with antimicrobial stewardship and open disclosure practices.

   Risks: Incidents were not always reported or investigated within the required timeframe, including psychological abuse allegations.

   Recommendations: Education program for staff on reporting procedures.; Updated communication systems and revised reports with better information.

   Generated by qwen2.5:32b on 11 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

5. Accreditation decisionDec 22, 2022

   Following a site audit conducted on 18 June 2019 to 20 June 2019, the Commission made a decision 14 July 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 22 December 2022. The period of accreditation of the service will expire on 13 February 2023.

   source ↗
6. Site audit Performance ReportDec 8, 2022

   A site audit was conducted with this service on 06 December 2022 to 08 December 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

   source ↗
7. AssessmentJun 20, 2019

   Following an audit we decided that this service met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 13 August 2022.

   source ↗
8. AssessmentJul 23, 2015

   Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 13 October 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 13 August 2019. The reconsideration decision and audit report is attached.

   source ↗
9. AssessmentJul 23, 2015

   Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 13 October 2018.

   source ↗
10. AssessmentAug 8, 2012
    source ↗
11. AssessmentAug 13, 2009
    source ↗

No regulatory actions recorded.